Patellofemoral pain: is there a role for orthoses?

A 28-year-old woman presents with right anterior knee pain of 3 months’ duration that occurs while she is running. To improve her overall fitness, she has been running 3 to 4 times per week (average, 12 to 15 miles per week) for the past 5 years. Before the onset of her knee pain, she had been gradually increasing the frequency of her training sessions and was running up to 4 to 5 times per week (average, 20 to 25 miles per week) in preparation for her first marathon. She has no history of knee injury or knee trauma. Her symptoms are exacerbated by running on hills (especially running downhill), performing squat exercises, and (most recently) traveling up or down stairs. The physical examination reveals a standing alignment notable for mild genu varum and pes planus. The patient experiences pain and medial knee collapse when performing a single leg squat. Bilateral mild heel valgus and moderate forefoot varus are noted. Her Q-angle is 20° on the right and 18° on the left. There is no evidence of knee effusion, swelling, or increased warmth. A 2 medial and 3 lateral patellar glide without evidence of patellar apprehension are noted. Palpation reveals tenderness of the medial patellar facet and lateral retinaculum that is not appreciated on the asymptomatic left side. Lower extremity flexibility is within normal limits and is symmetrical for the hamstrings, rectus femoris, psoas, and gastroc-soleus musculature. The Ober test reveals mild bilateral iliotibial band tightness. The results of a neurologic examination are within normal limits, except for the 5 /5 strength of the right hip abductors when the patient is tested while lying on her side. Radiographs (standing anteroposterior, lateral, and notch views) reveal no degenerative changes or osteochondral defects. There was evidence of mild lateral patellar tilt on the Merchant view. Previous treatment, which resulted in only mild relief, included 8 visits for physical therapy focusing on quadriceps strengthening, hamstring flexibility, and wall squats. A 4-week course of antiinflammatory medication also did not alleviate the patient’s pain. Her overall presentation is consistent with the diagnosis of patellofemoral pain. Her primary care provider has referred her to you to determine whether orthotics or any other therapeutic options are feasible and likely to be effective. Which further assessment and treatment do you now recommend? Guest Discussants: